Evaluating a HIV Prevention Program AMONG People Who Inject Drugs in Southwest China Using Coarsened Exact Matching (CEM) Kai Wang Hongyun Fu Kim Longfield Shilpa Modi Gary Mundy Rebecca Firestone Evaluation 2013 October 17, 2013

Overview of the Presentation Background Methods Results Conclusions

HIV/AIDs in Yunnan and Guangxi 1989: China reported first AIDS cases among 146 heroin users in Yunnan Yunnan is located near the golden triangle. The overall HIV prevalence in China is low (0.06%), however, the prevalence rates of HIV were among people who inject drugs (PWID) was 6.4%, with prevalence higher than 50% in parts of southwest China. Yunnan and Guangxi Provinces account for 22% the total HIV cases in China despite making up only 6.9% of the national population in the country New cases between Jan – Oct 2012: 68802, Sexual transmission accounts for 84.9% (homosexual transmission - 21.1% relative to 15% in 2011) HIV prevalence rates were 6.4% among PWID, 6.7% among among MSM, and 0.3% among FSWs in 2011. - 6.7% The reported HIV among PWID account for 87.2 of all total estimated HIV cases in China

Yunnan program sites map HXH - PSI directly implements community-based IDU CPP interventions (including Drop-In-Center based and outreach activities and outreach into MMT clinics and communities) and provide TA to the community rehabilitation and recovery centers run by the local government SAA – PSI, Pact and RTI provides capacity building to SAA to promote long-term sustainability of CPP interventions through local CBOs Daguan, Lianmeng , Xiyuanliangyuan , Jinma CHC – member of the Clinical Health Network (CHN), which provide HIV, STI, TB, Hepatitis screening and counseling for MARPs, in collaboration with Kunming Municipal AIDS Bureau Pact and RTI – Pact working with SAA to implement capacity development plans for 3 CBOs. RTI working with Yunnan Govt to operationalize the social Service Outsourcing (SSO) initiative Yunnan program sites map Poplar Tree - PSI providing TA and financial support to this IDU peer-led grassroots group to promote community based IDU CPP interventions KUNMING GEJIU MENGZI Kangxin Home – PSI provided TA and financial support to this IDU peer-led grassroots group to promote community based IDU CPP interventions – support completed December 2012

Background: Comprehensive HIV/AIDS Prevention Package (CPP) targeting MARPs Policy Stigma and Discrimination Behavioral Change Community Mobilization HIV Counseling and Testing STI Treatment MARPs PLHA Harm Reduction Condom Distribution Livelihood Development Strategic Information Linkages to Care and Support Capacity Building 5

Methods Summary of method: A behavioral tracking survey in 2012 (cross-sectional survey) Face to face interview (self-report data) Structured questionnaire Yunnan Institute for Drug Abuse IRB Review Respondent-driven sampling 1035 samples in four cities

Methods - Sampling Respondent-driven Sampling (RDS) Seeds selection Criteria: Age: <24; 24-40; >40. Gender: Male; Female. Current IDUs and Former IDUs. Current MMT user and non-user. Exposed; Non-exposed Seeds Number: 8 seeds in Kunming; 7 seeds in Nanning; 4 seeds in Gejiu; 4 seeds in Luzhai. Wave: 12 waves (the best seed)

Methods - Including Criteria Study population: Participants were recruited from the social networks of PWID which were living in the local communities, and not residing in compulsory detox centers. Aged 18-49 (as measured according to the Western calendar and determined by participant self report) Had injected drugs in past 12 months Resident in the communities in either Kunming city, Gejiu, Luzhai or Nanning city for a minimum of 1 month. Can speak and comprehend Mandarin to a sufficient level to respond to survey questions

Methods – Sample size In total: 1035 Gejiu 204 Kunming 336 Nanning 355 Luzhai 11 140 In total: 1035

Methods – Data Analysis RDS weights City weights Coarsened Exact Matching (CEM) weights Matching variables：1) Age; 2) Gender; 3) City 4); Working time (whether convenient to attend program activities); 5) Ever MMT use Results: 975 cases matched /1035 samples, L1 distance : 2.83 E-16 Logistic regression

Results: Population Characteristics Sex (Male) 67.4% Age (in years) 18-40 48.4% 41-49 51.6% Ethnicity (Han) 83.3% Education (High school education or above) 31.1% Marital status Never married 42.6% Currently married or 57.4% divorced or widowed Ever received methadone maintenance treatment (MMT) 87.9%

Results: Behaviors outcomes

Results: Exposure to DiC and outreach

Results: Effectiveness of DiC and outreach Never shared needles or syringes in past 3 months Predictors Matched sample: (n=762) Bivariate Multi-variate OR, 95% CI Adjusted OR, 95% CI Program exposure Participated in DiC-based intervention in past 12 months 0.76 (0.39-1.48) (0.37-1.56) Participated in outreach in past 12 months 0.91 (0.45-1.85) 1.04 (0.49-2.24) Ethnicity (Han) --- 0.39 (0.09-1.70) Education (High school education or above) 2.79* (1.18-6.61)

Results: Effectiveness of DiC and outreach Kept a new needle on hand in past 3 months Predictors Matched sample: (n=762) Bivariate Multi-variate OR, 95% CI Adjusted OR, 95% CI Program exposure Participated in DiC-based intervention in past 12 months 1.59** (1.17-2.17) 1.47* (1.05-2.06) Participated in outreach in past 12 months 1.48** (1.07-2.05) 1.28 (0.90-1.83) Ethnicity (Han) --- 1.43 (0.86-2.38) Education (High school education or above) 1.13 (0.82-1.56)

Results: Effectiveness of DiC and outreach Tested for HIV in past 12 months (Kunming) (Gejiu, Nanning, and Luzhai) Predictors Matched sample: (n=324) (n=650) Bivariate Multi-variate OR, 95% CI Adjusted OR, 95% CI Program exposure Participated in DiC-based intervention in past 12 months 2.06** (1.25-3.40) 2.07** (1.22-3.50) 1.38 (0.97-1.97) 1.17 (0.80-1.70) Participated in outreach in past 12 months 1.35 (0.81-2.26) 1.19 (0.68-2.07) 2.26*** (1.37-3.73) 2.04** (1.20-3.44) Ethnicity (Han) --- 2.04 (0.90-4.63) 1.03 (0.70-1.52) Education (High school education or above) 1.60 (0.93-2.76) 1.66* (1.10-2.51)

Results: Effectiveness of DiC and outreach Consistent condom use with all partners in past 3 months Predictors Matched sample: (n=500) Bivariate Multi-variate OR, 95% CI Adjusted OR, 95% CI Program exposure Participanted DiC-based intervention in past 12 months 2.26*** (1.62-3.16) 2.29*** (1.57-3.35) Participated in outreach in past 12 months 1.68** (1.17-2.41) 1.38 (0.91-2.10) Ethnicity (Han) --- 0.66 (0.38-1.14) Education (High school education or above) 1.94*** (1.34-2.82) No. of Sexual behavior in past 3 months 0.97*** (0.95-0.98)

Conclusion Peer-led programs reduced HIV risk among PWID. The DiC-based activities in Yunnan and Guangxi were successful at increasing safe injecting practices, HTC, and consistent condom use. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grass roots organizations. Outreach was most effective for referring PWID into HTC, and appears to increase awareness of DiCs where PWID can receive more intensive services and private HTC. The CEM procedure improved the causal inference and gave stronger evidence for evaluating the impact.

Thank you! Questions? PSI